Your comeback can help the next patient.

By checking the box, I confirm that I am at least 18 years old (or the parent or legal guardian of the patient), that the story and any photos or video are mine to share, and that no one else who appears in them objects. I understand the practice may choose not to publish my story, may remove it later, and is not obligated to use it. I release the practice and its staff from claims arising from the use of my story as described here. I understand that once something is published on the internet it may be copied by others and the practice cannot recall those copies.

What will be shared: the story you write, your first name and last initial, your city and state, your likeness in any photos or video you submit, the condition or treatment you name, the approximate date of your care, and the fact that Dr. Gerlach was your physician. Nothing from your medical record is shared unless you write it in your story.

Who is sharing it: Erik Gerlach, M.D. and Indiana Spine Group.

Who will receive it: anyone who visits gerlachspine.com or the practice’s social media channels, and IndexMed, the platform the practice uses to receive and review submissions.

Purpose: to share your experience with other patients and the public.

Expiration: this authorization ends 10 years from the date you submit it, unless you revoke it sooner.

Your rights: you may revoke this authorization at any time by calling (317) 893-1250. Revocation takes effect going forward; it cannot recall what has already been published or copied by others. Your care, payment for care, and benefits do not depend on signing this. Once shared publicly, your information may no longer be protected by federal privacy law and could be re-disclosed by others.